[HEALTH PLAN OR MEDICAL GROUP/IPA LETTERHEAD]
(Use 12-point Font)
COMMERCIAL
Extension Needed (Urgent, Non-Urgent or Post-Service) due to:
Additional Information Needed or Opinion is Required by an Expert Reviewer
(Must be issued when determinations cannot be made within required timeframes)
[Date]
[Name of Member] / Member Name:[or Member’s representative] / DOB:
[Address] / Member ID#:
[City, State, Zip code] / Health Plan Name:
Requested Provider:[use when a specific provider requested]
Requested Service:
Requesting Provider/Physician:
Dear [Member’s Name]:
This correspondence is in response to your request or your physician’s request on [insert date] for the above referenced service. In some instances [insert Health Plan or Provider Organization Name] needs additional time in order to obtain all the necessary information to render a determination.
Information has been requested but has not been received or the information received to date is insufficient to render a determination.
In the case of your request, the following extension is required:
We are requesting [insert one: Urgent: additional information be submitted within 48 hours. A decision will be made within 48 hours of the receipt of the information. The physician reviewer is unable to make a determination on the service request based on available information. If we do not obtain additional information by this deadline, we may have to issue a denial. Your physician can re-submit the request for authorization at a later date.
or Non-Urgent: additional information be submitted within 45 calendar days. A decision will be made within 5 business days of receipt of the requested information. The physician reviewer is unable to make a determination on the service request based on available information. If we do not obtain additional information by this deadline, we may have to issue a denial. Your physician can re-submit the request for authorization at a later date.
or Post-Service: additional information be submitted within 45 calendar days. A decision will be made within 15 calendar days of receipt of the requested information. The physician reviewer is unable to make a determination on the service request based on available information. If we do not obtain additional information by this deadline, we may have to issue a denial. Your physician can re-submit the request for authorization at a later date.
or Expert Review: an opinion from an Expert Reviewer. A decision will be made 15 calendar days from the date of this notice.]
Specifically, [insert: for additional info: specific information needed and from whom or for expert review: type of expert reviewer].
During this extension, please [as applicable, describe what the enrollee must do in lay terms (ex. note that there is no action required by you the member at this time. We are requesting the additional information from your provider in order to process this request.)]
Thank you for your patience during this process. Please direct any further questions or information to [insert Health Plan or Provider Organization Department or individual’s name] at [insert phone number and/or fax number].
Sincerely,
______
[Insert Health Plan or Provider Organization Name and Title]
[Insert all that apply]
C. Member File
[Requesting Physician name]
[Primary Care Physician name]
Health Plan
1
ICE Delay/Extension (CO), Issued 6/02
Revised: 12/02, 8/04, 6/06, 11/07, 10/08 (PacifiCare)